Jan 242011
 

None of us are robots so none of us are perfect. After years of earning a reputation for safe working the brain skips a beat, misses a groove like scratched vinyl record. Some folk call it a brain-fart which, if you’re hungry for long words to put in your next powerpoint presentation, is technically called a maladaptive brain activity change.

Perhaps that is what happened when a normally safe worker maaged to accidentally break a deckhands finger in the latest safety alert from Marine Safety Forum.

Here’s what happened:

During a maintenance period it became necessary to deballast a Methanol tank. Because of the envisaged high work load there were three C/Os onboard and additional staff, the senior C/O
instructed the 2nd C/O to deballast the starboard tank through the port manifold Avery Hardoll connection to sea.

It was known that the non return valve (NRV) was not in place.

The 2nd C/O had noted the day before that the line was open and the cap was off and started the pump, However, there was immediate back pressure on the gauge and no discharge was noted.

It was concluded that the cap must have still been on the line and so the 2nd C/O instructed a deckhand (the Injured Person) to remove the Avery Hardoll cap. The IP stood to one side, and tried to move the cap by hand, but was unsuccessful and therefore tapped it with a hammer.

The cap was ejected from the manifold and struck the IP on his right hand, lacerating and breaking his index finger.
Key Lessons:
The cap had not been removed from the discharge manifold prior to energising the pump and pressurising the line. The assumption that the line was open was clearly wrong. The 2nd C/O was experienced, was the subject of good reports, was not fatigued and acknowledged awareness of the procedure and the responsibility to ensure the lines were set up and the cap removed.

Had procedures been followed the accident would not have happened.

Furthermore, had the Avery Hardoll connection been complete with its non-return valve operating as designed, it would have sealed the pipe-work, preventing any pressure build up behind the cap.
The 2nd C/O acted out of character, made an incorrect assumption and did not follow procedures, further the risks associated with not having a NRV in place were not considered. Having made the initial misjudgement and as a consequence pressurised the line, the task should have been stopped and a new tool box talk convened to consider the risks and take appropriate action to mitigate them.
The incident was a direct result of a failure to follow procedure and to stop the job once a deviation from the norm was experienced.

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